Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2021.16

Headache Medicine

Editorial

International Classication of Headache Disorders - ICHD-4. Will

medication-overuse headache survive?

Mario Fernando Prieto Peres

, Thaiza Agostini Córdoba de Lima

, Marcelo Moraes Valença

2,3

Instituto de Psiquiatria, HCFMUSP, São Paulo, Brasil

Unidade de Neurologia e Neurocirurgia, Universidade Federal de Pernambuco, Recife, Brasil

Unimed Recife, Recife, Brasil

The fourth edition of the International Classication of Headache Disorders (ICHD-4) initiatives has

been already started. A new Classication Committee leadership with Dr Peter Goadsby (chair)

and Dr Stefan Evers (secretary) took over Professor Jes Olesen, who has made an incredible effort

leading the rst three editions.

1-4

The current leaders published a letter asking for comments, suggestion for changes or improvements

on the ICHD-3.

It has already been suggested two interim modications; rst, in

Denition of Terms

episodic migraine was included, dening it as a headache frequency of fewer than 15 days a

month over the last 3 months, which on some days is migraine. The second, premonitory symptoms

denition was corrected.

Although the extensive work and advances in the eld were achieved with the rst three editions, its

current status is still far from ideal.

Some issues are more urgent than others. The main weakness, in our opinion, is the criteria for

medication-overuse headache (MOH) (Figure 1). The current description states that MOH develops

“as a consequence” of regular overuse of acute medication; however, the criteria do not require

any aspect of the causal relationship with acute medication use and the development of a chronic

headache disorder.

Medication-overuse headache criteria do not include the denition of overuse; this is a signicant

drawback, by the current criteria; acute medication use, misuse, overuse, or abuse may be inade-

quately included, although each has a completely different meaning.

It is unsustainable for such a diagnosis without an operational denition of its main aspect: the word

“overuse”. The criteria in item B on 8.2.1 to 8.2.8 describes “regular intake” for “≥15 days/month for

>3 months” in 8.2.3 and ≥10 for all the others. Therefore, what the current MOH diagnostic criteria

is diagnosing is nothing but “frequent analgesic use”. Not only the lack of operational denition

of overuse causes MOH to be ill-dened; even more confusion is brought when reading the third

paragraph of the Comment section:

“The behaviour of some patients with 8.2 Medication-overuse headache is similar to that seen

with other drug addictions, and the Severity of Dependence Scale (SDS) score is a signicant

predictor of medication overuse among headache patients.”

Mario Fernando Prieto Peres

mariop3r3s@gmail.com

Received: August 28, 2021

Accepted: September 23, 2021

ASAA

Peres MFP, Lima TAC, Valença MM

International Classification of Headache Disorders - ICHD-4. Will medication-overuse headache survive?

Figure 1. ICHD-3 Diagnostic criteria for 8.2 Medication-Overuse Headache.

ASAA

Peres MFP, Lima TAC, Valença MM

International Classification of Headache Disorders - ICHD-4. Will medication-overuse headache survive?

This paragraph is misleading in directing the physician in

understanding overuse as abuse, addiction, or dependence.

If MOH is then abuse, or addiction, or dependence, the

specic criteria should be included. The trend in psychiatric

diagnosis for substance abuse disorder in the DSM-V is to

merge dependence and abuse into one set of criteria with

11 aspects6, which are not fully applicable in the reality

of headache disorders and acute medication relief. The

Severity of Dependence Scale suggested by the comments’

paragraph also has limited applicability.

The next paragraph in the comments states that the number

of days of medication use was dened based on expert

opinion and not evidence. This is unacceptable in a eld

already signicantly advanced in its scientic basis, no more

expert opinions should be the basis of diagnostic criteria

from now on.

“In the criteria below for the various subtypes, the

specied numbers of days of medication use con-

sidered to constitute overuse are based on expert

opinion rather than on formal evidence.”

Moreover, MOH criteria generate a clinical practice di-

lemma, they do not accept relief in a headache day when

it is the 11th or 16th headache day. If a patient has daily

headaches for more than 3 months, half of their headache

days will not be acutely treated.

Evidence is lacking in establishing the cause-effect of acute

medication use and the worsening of headaches. Also,

criteria for this aspect must be dened.

References

1. Headache Classication Committee of The Interna-

tional Headache Society. Classification and diagnostic

criteria for headache disorders, cranial neuralgias and

facial pain. Headache Classification Committee of the

International Headache Society.

Cephalalgia

1988;8

Suppl 7:1-96

2. Headache Classication Committee of The International

Headache Society. The International Classification of

Headache Disorders: 2nd edition.

Cephalalgia

2004;24

Suppl 1:9-160 Doi:10.1111/j.14 6 8 -2 982.2 0 03.0 0 824. x

3. Headache Classification Committee of The In-

ternational Headache Society. The International

Classification of Headache Disorders, 3rd edition

(beta version).

Cephalalgia

2013;33(9):629-808

Doi:10.1177/0333102413485658

4. Headache Classication Committee of The Interna-

tional Headache Society. Headache Classification

Committee of the International Headache Society

(IHS) The International Classification of Headache

Disorders, 3rd edition.

Cephalalgia

2018;38(1):1-211

Doi:10.1177/0333102417738202

5. Goadsby PJ and Evers S. International Classification

of Headache Disorders - ICHD-4 alpha.

Cephalalgia

2020;40(9):887-888 Doi:10.1177/0333102420919098

6. Livne O, Shmulewitz D, Stohl M, Mannes Z,

Aharonovich E and Hasin D. Agreement between DSM-

5 and DSM-IV measures of substance use disorders

in a sample of adult substance users.

Drug Alcohol

Depend

2021;227:108958 Doi:10.1016/j.drugalc-

dep.2021.108958